Harm Reduction

1
Harm Reduction
When Methadone Becomes a New Medicine

• Ontario Aboriginal HIV/AIDS Strategy

2
Our Values Prior to Contact

• Many tribes are matriarchal
• All genders hold special stations and roles
  including our Two-Spirited People
• Womens and Two-Spirited Peoples council is
  sought before decisions are made effecting the
  tribe
• Men play a role in the decision-making process,
  they do not have sole control over it.

3
History Impacts

• Entire Tribes such as the Beothuk are wiped out
  of existence
• Foreign diseases wipe out 90 of indigenous
  populations
• Treaties, the 60s Scoop, Residential Schools
  take their toll

4
Intergenerational Impacts of Residential School

• All sex becomes bad
• Homosexuality is equated to same-sex sexual
  abuse
• Brothers and sisters are separated
• Skills and roles within the family and community
  breakdown

5
New Realities For Women

• Not all women have berry-fasted
• Not all women have been to a Full Moon Ceremony
• Women, including Two-Spirited Women are being hit
  hard by HIV, STIs, domestic violence, unplanned
  pregnancies and increased dependence on substances

6
Alarming Rates

• There are an estimated 58,000 people living with
  HIV in Canada
• Aboriginal People make up 3.3 of the Canadian
  population, yet 16.4 of all new HIV cases by 2005
  where ethnicity was known
• It is estimated that there are 573 Aboriginal
  cases of HIV/AIDS
• The low estimate is that for every Aboriginal
  person that knows their HIV status, 10 Aboriginal
  people do not

7
Alarming Rates

• Ontario and Quebec represent 85 of Canadas
  population, 95 of new infections, yet do not
  record ethnicity
• Of reported Aboriginal cases, 53 are IDU, 33
  heterosexual, 10 MSM, and 3 MSM-IDU
• 32.2 of Aboriginal cases are under 30 yrs. old
• Our women make up 47.3 of new Aboriginal HIV
  infections
• Of Aboriginal IDU infections, our women make up
  34.9

8
Harm Reduction

• Many programs and services take an
  abstinence-based approach as a condition of care.
  This conditional love usually means the women
  who really need your support arent being served
• Harm Reduction does not judge her. Instead, it
  respects her right to make her own decisions,
  allows her dignity in her life and strives to arm
  her with the tools she needs to reduce any harm
  being experienced by herself and children
• Harm Reduction accepts her where shes at in
  relation to the substance use continuum

9
New Skills Replace Old Skills

• Our history can destroy, steal or blur our roles
  and responsibilities within our family and
  community
• Life skills, parenting skills survival skills
  become improvised to fill these voids
• Substances can become used to numb this pain
• This pain-killing requires new skill-sets
• Does your client know her dealer, know how to
  safely inject herself, make a plan, safely deal
  with used needles in the home?

10
The Power of Words

• There are 4 stations with flip-chart paper and
  markers each with a different question
• Participants will be divided into 4 groups and
  have a different colour marker for each group
• Each group will spend time at each station
  brainstorming and adding their comments to each
  flip chart
• Each group elects a reporter
• Discussion and debriefing will follow.

11
Opiate? Opioid?

• Opiates are made from the Poppy to make opium,
  morphine codeine, but can also be changed to
  make heroin
• Opioids include the opiates listed above AND
  other drugs with morphine-like effects
• These are not made from the Poppy, and include
  methadone, Demerol, Percodan, Dilaudid, etc.
• Opioid drugs are analgesics (pain-killers)

12
Killing Pain

• If you stub your toe your body produces
  endorphins to kill the pain
• If you break your leg, endorphins arent enough.
  Youd be prescribed morphine as the bone is set,
  then codeine to kill the pain as the bone heals
• Some people dont need to break bones to want to
  kill their pain
• Methadone Maintenance Treatment (MMT) is taken
  orally and doesnt give the heroin high
• MMT prevents withdrawal for 24 36 hours

13
MMT in Ontario

• 650 clients in Ontario were on MMT in 1996
• 7,787 were on MMT by 2001
• In NWO alone, in 2005 there were over 700
  Aboriginal people on MMT, however since the OATC
  arrived about 18 months ago, the numbers must be
  considerably higher
• Current public health policy recognizes the
  priority to reduce the harm to people contracting
  life-threatening diseases from using needles, and
  dying from overdose at alarming rates

14
MMT Assessment

• This holistic assessment first looks at the
  physical and will require a urine test (to
  confirm opioid dependence), sometimes a chest
  X-ray to check for TB and informed consent before
  blood-work to check for HIV and/or Hepatitis
• To assess physical and mental health your client
  will be asked very personal questions about her
  home-life and family-life, her work and any
  dealings she had or has with the law
• You can prepare her for this and encourage her to
  answer as honestly as possible

15
Starting MMT

• She will be asked to sign a consent form
• Her name will be added to the Methadone Registry
  of the College of Physicians and Surgeons of
  Ontario to eliminate the possibility of
  double-dipping or overdose
• This registry is not seen by her employer, the
  police, welfare or Childrens Aid
• She will more than likely also be asked to sign a
  treatment agreement

16
Getting her dosage correct

• She will usually be started anywhere from 15 30
  mg per day
• Stabilizing her dosage takes from 2 6 weeks
• Missing a dose shouldnt make her jones like
  she were on heroin
• The first goal of MMT is to find a dose that
  helps her not use other opioids
• If the Dr. prescribes a higher dose, theres a
  reason
• She may be given a split-dose and have to
  undergo blood tests throughout the day to check
  how quickly she is burning up her methadone

17
Drug Interactions

• Methadone overdose rarely occurs but if it does,
  it usually happens within 8 days of starting MMT
• This is usually due to combining MMT with other
  opioids, alcohol or other downers including
  valium
• Other prescription meds can influence her dose,
  but does not mean she cant start MMT
• A stable dose is from 60 100 mg per day

18
Carrys

• After about two months of drug-free urine tests
  she may be eligible to sign a Carry Agreement
  (home delivery is rare)
• She could be charged if someone else ingests her
  dose (lost Carrys should be reported to the
  police)
• Carrys should be locked, and CAN be kept at room
  temperature

19
Travel

• She can be issued a Methadone Client ID Card
• Advise her to keep this card, her Dr.s number,
  her pharmacy number and a contact number for a
  worker from her care team
• She may be able to guest dose when traveling
  from province-to-province or abroad
• Canada/US Customs officially consider traveling
  across the border with Carrys illegal (but its
  done, unofficially)

20
Bed-ridden Client

• In severe illness, some pharmacies will deliver
  her dose to her, but expect the delivery person
  to stay and watch her ingest her dose and take
  back the Carry container
• If she goes to jail she should be able to
  continue her MMT
• Its unlikely shell be able to start MMT once
  shes in

21
How Much Does It Cost?

• OHIP should cover MMT costs except travel
• No OHIP, costs usually run from 4 - 15 per
  days dose
• Ontario Works or ODSP cover some or most costs,
  or the Ontario Drug Benefits Program (Trillium)
  may also be an option for low-income ladies
• Some workplace drug benefits packages are
  progressive enough to include this in her
  benefits package

22
Access

• www.oatc.ca includes maps to find out the nearest
  clinic within your mandated area
• A community pharmacy can dispense MMT if they
  choose to
• The process would be like picking up a
  prescription she arranged in the big city
• She would still have to talk to her MMT Dr. about
  urine testing on-going assessments

23
Birth Control

• Opiates and Opioids may stop your Moon time
• It is OK to take birth control
• As opioid use lessens, Moon times start
• The chances of pregnancy also increase
• Stopping opioids before getting pregnant is
  easier on mom and the baby

24
Pregnancy

• Agencies should not force abortion on a woman
• Heroin highs and withdrawal thresholds threaten
  your baby more than MMT
• Changing from heroin to MMT during pregnancy is
  easier in the hospital
• An MMT pregnancy does not cause deformities
• A womans baby should not automatically be taken
  away simply because she is on MMT
• A good plan can keep mom and baby together

25
Infant Withdrawal

• Some babies may experience withdrawal
• This can start within a few days or arise two to
  four months after birth
• This can last a few weeks or months
• The baby may be cranky, cry a lot, not eat or
  sleep well, have a fever, throw up, tremble or
  sometimes have seizures
• The hospital can medicate in severe cases
• Never give your baby Methadone

26
Breastfeeding

• Moms on low-dose MMT should be encouraged to
  breastfeed until about 6 months when larger
  amounts of breast-milk also means larger amounts
  of methadone
• A mom with Hep-C can also breastfeed
• If an HIV-positive mom breastfeeds, she should
  only breastfeed and not switch back and forth
  between breast and formula
• Flash-heating is the newest tool being examined
  around breast-feeding and HIV

27
Menopause

• Hot flashes and sweating are a part of menopause
  whether your client is on MMT or not
• Sweating (one possible side effect of MMT)
  combined with menopause may means she may sweat
  profusely
• Hormone Replacement Therapy (HRT) is still an
  option for ladies on MMT
• She can discuss HRT and other treatments with
  other women and her doctor

28
The Teaching of Non-interference

• Although we have had camp fires for many
  centuries, how often do you hear about a child
  accidentally being burned to death in one?

29
The Circle People

• This is how they see the world
• This is what works for them
• Thats fine

30
The Square People

• This is how they see the world
• This is what works for them
• Thats fine

31
A Circle Trying to be a Square

• Adds the arches that are not part of the square

32
A Circle Trying to be a Square

• Excludes the corners that are part of the square

33
A Square Trying to be a Circle

• Adds the corners that are not part of the circle

34
A Square Trying to be a Circle

• Excludes the arches that are part of the circle

35
Life Experience of the Circle

• These arches represent the life experience of the
  circle
• The circle will never truly understand or own the
  life experience of a square

36
Life Experience of the Square

• These corners represent the life experience of
  the square
• The square will never truly understand or own the
  life experience of a circle

37
The Human Experience

• The lesson is not to get caught up in the arches
  and the corners, but to embrace what is common

38
Rope Exercise

• Rope exercise to provide experiential learning
  about inclusion and exclusion from the Circle.

39
Additional Resources

• Aboriginal HIV/AIDS Workers
  www.oahas.org
• Centre for Addictions Mental Health
  www.camh.on.ca
• AIDS Statistics (Epi-updates, August 2006)
  www.phac.aspc.gc.ca
• Harm Reduction www.ccsa.ca
• Prisoners with AIDS Support Action Network
  www.pasan.org
• Ontario Addictions Treatment Centres
  www.oatc.ca
• D.A.R.T. (Drug Alcohol Registry of Treatment)
  1-800-565-8603
• Methadone Registry
  1-416-967-2600